Anemia Severely Reduces Health-Related Quality of Life in COPD Patients Receiving Long-Term Home Non-Invasive Ventilation

Preoperative ANemiA among elderly undergoing Major Abdominal surgery (PANAMA) is associated with early postoperative morbidity and worse quality of life outcomes

Preoperative anemia is associated with poor outcomes, but less is known about its impact on quality of life (QoL). This study investigates the association between preoperative anemia and QoL in elderly undergoing major abdominal surgery. This prospective observational study was conducted from 2017 to 2021 in a tertiary hospital's preoperative anesthesia clinic. QoL outcomes were assessed using the EuroQol 5-Dimension 3-Level (EQ-5D-3L) and the EuroQol-Visual Analogue Scale (EQ-VAS). Data was collected at baseline, 1-, 3-, and 6-month postoperatively. Patients were included if they were 65 years or older, could provide written informed consent and were planned for elective major abdominal surgery. Patients were excluded if they were going for organ transplant surgery. A total of 469 patients were analyzed, of which 176 (38%) had anemia. There was no significant difference across varying anemia severity in EQ-5D-3L dimensions of mobility, self-care, usual activities, and pain/discomfort. Moderate-to-severe anemic patients generally have more issues across EQ-5D-3L dimensions. At baseline, these patients exhibited more issues with self-care (3%), pain/discomfort (13%), and anxiety/depression (19%), along with a lower mean EQ-VAS score of 77. However, there was a significant improvement in mobility, usual activities, and pain/discomfort over time. EQ-VAS score significantly improved for all groups of patients over time. The dimensions of EQ-5D-3L and EQ-VAS scores improved as the severity of anemia decreased. Preoperative anemia is associated with a significant decrease in QoL based on EQ-VAS. Recognizing and managing preoperative anemia may improve the recovery of elderly patients undergoing major abdominal surgery.

[Long-term health-related quality of life of patients after prolonged weaning depending on weaning status]

INTRODUCTION

Long-term outcome in patients with prolonged weaning is known to be impaired, particularly against the background of their weaning status; however, data on their health-related quality of life (HRQL) are sparse.

METHODS

HRQL was measured in patients with prolonged weaning using the Severe Respiratory Insufficiency Questionnaire (SRI).

RESULTS

Overall, 39 out of 83 patients with prolonged weaning filled in the SRI questionnaire. The median interval between discharge from hospital and HRQL assessment was 3.5 years (IQR 2.4-4.5 years). In the total group, the median SRI summary score was 56.4 (IQR 38.8-73.5). Patients with unsuccessful weaning and subsequent invasive home mechanical ventilation (N=15) had worse HRQL as estimated from the SRI summary score when compared to those with successful weaning both without (n=13) and with subsequent long-term non-invasive ventilation (NIV) (n=11); Kruskal-Wallis-Test: H (2, n=39) = 7,875446; P=0.0195. Statistically significant differences indicating worse HRQL in patients with invasive home mechanical ventilation were particularly evident in the following SRI subscales: Social relationships (P=0.0325), Anxiety (P=0.0096), and Psychological well-being (P=0.0079).

CONCLUSIONS

HRQL is substantially impaired in patients with unsuccessful prolonged weaning and subsequent invasive home mechanical ventilation compared to those with successful prolonged weaning. Further studies incorporating higher case numbers are needed to assess other conditions potentially affecting HRQL in patients with prolonged weaning.

Defining a phenotype of severe COPD patients who develop chronic hypercapnia

INTRODUCTION

Chronic hypercapnia, defined by elevated blood CO2 levels, is a serious complication most prevalent in severe COPD. It negatively impacts quality of life, increases hospitalization rates, and elevates mortality risks. However, not all severe COPD patients develop chronic hypercapnia, and its underlying mechanisms remain unclear. Identifying clinical and pathophysiological predictors of hypercapnia is essential for tailored treatment strategies. This study investigates the relationship between hypercapnia and patient characteristics, lung function, and CT scan features to identify potential therapeutic targets.

METHODS

This cross-sectional study included 1526 COPD patients from three cohorts: a standard care cohort and two research cohorts (NCT04023409; NCT03053973). Data collected included demographic and clinical information, blood gases, lung function (FEV1, FVC, TLC, RV, DLCOc), and high-resolution CT scans (lung volumes, air trapping, emphysema scores, airway wall thickness (Pi10), and diaphragm indices).

RESULTS

Hypercapnia prevalence increased with COPD severity. Hypercapnic patients were older, more likely to smoke, and had more comorbidities. They exhibited lower FEV1 and FVC, and higher RV/TLC ratios, with CT scans showing lower emphysema scores and greater Pi10. Multivariate analysis identified lower PaO2, FEV1% predicted, and emphysema scores, along with higher RV/TLC ratios and NT-proBNP levels, as independent predictors of PaCO2, collectively explaining 46.3 % of the variance.

CONCLUSION

COPD patients with chronic hypercapnia are characterized by higher smoking rates, lower PaO2 levels, poorer lung function, less emphysema, and increased airway pathology. These findings underscore the multifactorial nature of hypercapnia in COPD, highlighting the need for personalized therapeutic strategies targeting these factors to improve outcomes.

Factors Associated With Change in S3-NIV Score Over Time in People With Chronic Respiratory Failure Treated With Long-Term Home Noninvasive Ventilation

INTRODUCTION

Monitoring changes in symptoms over time during long-term nocturnal home non-invasive ventilation (NIV) using patient-reported outcome measures is crucial. This study aimed to identify factors associated with changes in the S3-NIV total score, its two domains ("respiratory symptoms" and "sleep and NIV-related side effects") and individual item responses.

METHODS

We conducted a retrospective, longitudinal data analysis of a cohort of adults with chronic respiratory failure treated with NIV. Data were obtained from a French homecare provider. Multivariate linear and multinomial ordinal mixed effect models were used to identify factors associated with changes in S3-NIV scores over time.

RESULTS

Median follow-up was 2 years for 2135 participants. Each participant completed a median of five S3-NIV questionnaires; totaling 11,359 analyzed questionnaires. Type of respiratory condition, sex, age and time since NIV initiation were associated with change in S3-NIV score over time. NIV adherence was not associated with total S3-NIV score but high adherence was associated with more severe respiratory symptoms and an improvement in sleep and NIV-related side effects during the follow-up. Intensity of pressure support was associated with a lower total S3-NIV score and more side effects. Face masks and supplemental oxygen were associated with a lower S3-NIV total score.

CONCLUSION

Changes in S3-NIV scores over time are associated with the individual's characteristics and NIV settings. Analysis of the two domains and individual items of the S3-NIV could increase understanding of the difficulties experienced by people on NIV.

[Home mechancial ventilation: quality of life and the final stage of life]

The evaluation of health-related quality of life (HRQL) has gained importance in recent years. Disease-specific questionnaires are available for respiratory insufficiency, which enable the assessment of HRQL. The Severe Respiratory Insufficiency (SRI) questionnaire, which was specially developed for patients with respiratory insufficiency, is ideal for quantifying the quality of life in patients receiving home mechanical ventilation (HMV). Studies using the SRI questionnaire demonstrated that the physical functioning of patients with chronic lung diseases of various etiologies is significantly impaired, but frequently without significant impairment of psychological well-being. Therefore, severity of the disease and HRQL do not necessarily correlate with each other.Both invasive and non-invasive mechanical ventilation can improve quality of life. Co-morbidity, and above all advanced age, have the highest negative predictive value with regard to in-hospital mortality and weaning failure. The number of patients older than 80 years who remain dependent on invasive HMV after prolonged weaning in Germany is increasing significantly. High dependence on invasive HMV is often associated with a loss of quality of life and autonomy. Thus, ethical issues of the continued treatment of ventilated patients at the end of life are discussed increasingly.After weaning failure, the indication for invasive HMV should be critically examined and should focus on potentially severely reduced quality of life and poor prognosis, as well as the patient's wishes. If previously agreed treatment goals can no longer be achieved during the course of invasive HMV, changing the therapy goals should be discussed within the clinical team, with the patient, their relatives and, if necessary, with legal representatives.In order to avoid overtreatment and unnecessary patient suffering during invasive HMV, advanced care planning should be started as early as possible and if necessary accompanied by palliative medical measures.

ERS International Congress 2023: highlights from the Respiratory Intensive Care Assembly

Early career members of Assembly 2 (Respiratory Intensive Care) attended the 2023 European Respiratory Society International Congress in Milan, Italy. The conference covered acute and chronic respiratory failure. Sessions of interest to our assembly members and to those interested in respiratory critical care are summarised in this article and include the latest updates in respiratory intensive care, in particular acute respiratory distress syndrome and mechanical ventilation.

Quality of life in patients with chronic respiratory failure on home mechanical ventilation

Home mechanical ventilation (HMV) is a treatment for chronic respiratory failure that has shown clinical and cost effectiveness in patients with underlying COPD, obesity-related respiratory failure and neuromuscular disease (NMD). By treating chronic respiratory failure with adequate adherence to HMV, improvement in patient-reported outcomes including health-related quality of life (HRQoL) have been evaluated using general and disease-specific quantitative, semi-qualitative and qualitative methods. However, the treatment response in terms of trajectory of change in HRQoL is not uniform across the restrictive and obstructive disease groups. In this review, the effect of HMV on HRQoL across the domains of symptom perception, physical wellbeing, mental wellbeing, anxiety, depression, self-efficacy and sleep quality in stable and post-acute COPD, rapidly progressive NMD (such as amyotrophic lateral sclerosis), inherited NMD (including Duchenne muscular dystrophy) and obesity-related respiratory failure will be discussed.

Long-term health-related quality of life in patients on home mechanical ventilation

Background

It is fundamental to optimize and retain health-related quality of life (HRQoL) in the long term in patients with home mechanical ventilation (HMV). Therefore, this study aimed to evaluate the evolution of the HRQoL in patients already established on HMV across a period of 5 years and whether the HRQoL is associated with mortality.

Methods

This was a 5-year longitudinal cohort study conducted in an Outpatient Ventilation Clinic. Consecutive patients on HMV for at least 30 days responded to the Severe Respiratory Insufficiency (SRI) questionnaire at inclusion and again at 5 years.

Results

A total of 104 patients were included (male 56.7%, median age 69 [P25;P75] [61;77] years). Almost half of the patients had COPD (49.0%). Patients were on HMV for a median of 43.5 [22;85.5] months, with overall good adherence (median 8 [6;9] daily hours). Fifty-seven (54.8%) patients were alive at 5 years. In surviving patients, the only difference with statistical significance was in the attendant symptoms and sleep subscale, with patients scoring 7.1 [-4.5;25] points higher in the final questionnaire (p = 0.002). Survivors had significantly better scores in the SRI at inclusion than deceased patients (median 59.6 [49.2;71.7] vs 48.7 [38.4;63.2]; p = 0.004).

Conclusions

These results shows that HRQoL remains stable in surviving patients with HMV at five years. It also suggests that SRI can be of important prognostic value and help predict the terminal phase of the disease course in patients with long-term HMV.

Pharmacological, Nutritional, and Rehabilitative Interventions to Improve the Complex Management of Osteoporosis in Patients with Chronic Obstructive Pulmonary Disease: A Narrative Review

Osteoporosis is a highly prevalent condition affecting a growing number of patients affected by chronic obstructive pulmonary disease (COPD), with crucial implications for risk of fragility fractures, hospitalization, and mortality. Several risk factors have been identified to have a role in osteoporosis development in COPD patients, including corticosteroid therapy, systemic inflammation, smoke, physical activity levels, malnutrition, and sarcopenia. In this scenario, a personalized multitarget intervention focusing on the pathological mechanisms underpinning osteoporosis is mandatory to improve bone health in these frail patients. Specifically, physical exercise, nutritional approach, dietary supplements, and smoke cessation are the cornerstone of the lifestyle approach to osteoporosis in COPD patients, improving not only bone health but also physical performance and balance. On the other hand, pharmacological treatment should be considered for both the prevention and treatment of osteoporosis in patients at higher risk of fragility fractures. Despite these considerations, several barriers still affect the integration of a personalized approach to managing osteoporosis in COPD patients. However, digital innovation solutions and telemedicine might have a role in optimizing sustainable networking between hospital assistance and community settings to improve bone health and reduce sanitary costs of the long-term management of COPD patients with osteoporosis.

Anemia in chronic obstructive pulmonary disease: A systematic review

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a type of obstructive lung disease that is characterized by poor airflow and airway inflammation. It is estimated that the global prevalence of COPD is about 13.1%. Anemia is associated with increased morbidity and hospitalization duration. In this systematic review, we investigate the association between all types of anemia and COPD progression.

METHODS

We systematically searched electronic databases, including Scopus, Medline/PubMed, EMBASE, Web of Sciences (WOS), and Cochrane Library, using the following mesh-standardized keywords: (((anemia∗ OR anaemia∗) OR "chronic anemia disease" [Mesh] OR "CAD" OR "iron deficiency anemia" OR" IDA" OR) AND ("COPD" [Mesh] OR "chronic obstructive pulmonary disease")) until February 2022.

RESULTS

Overall of 11,158 studies were included. Ultimately, 59 studies were included in the analysis. The most apparent findings from the analysis were that exacerbation of COPD, increased hospitalization, and increased long-term mortality were associated with anemia. Further analysis showed that iron deficiency (ID) is a common finding in COPD and is accompanied by an increase in the systolic pulmonary artery pressure.

CONCLUSION

Despite the comfortable control of anemia, the absence of treatment can be life-threatening in patients with COPD. Our systematic results showed significant homogeneity between studies on the increased mortality rate in anemic COPD, increased hospitalization, and decreased quality of life.

[Outcome in Prolonged Weaning - Results of a Regional Weaning Center]

BACKGROUND

 The number of patients with prolonged mechanical ventilation is increasing. Weaning units (WU) in the German network "WeanNet" are specialized in the treatment of patients needing prolonged weaning. In this study we present outcome data on the patients in our WU from 2011 to 2015.

METHODS

 A distinction is made between the 4 outcome groups: 1. Successful weaning without mechanical ventilation, 2. Successful weaning with non-invasive mechanical ventilation (NIV), 3. Weaning failure with subsequent invasive ventilation and 4. Death in the WU.

RESULTS

 In 272 patients, the following distribution within the 4 outcome groups was found: Group 1: 116 patients (42.6 %), Group 2: 52 patients (19.1 %), Group 3: 45 patients (16.5 %) and Group 4: 59 patients (21.7 %).The duration of treatment in the WU depended primarily on co-morbidities and the hemoglobin level.Despite successful weaning, the tracheostoma was completely closed in only 60.3 % of patients with continuous spontaneous breathing and 67.3 % of patients with NIV at the time of discharge from the clinic.After discharge from the WU, patients with weaning failure and subsequent invasive long-term ventilation, in contrast to patients with successful weaning, were rarely transferred to rehabilitation, but re-admitted more frequently to the clinic as emergency cases (29 %).The 1-year survival rate was 59 %. Half of the patients died in less than 2 years.

CONCLUSION

 The majority of patients with prolonged mechanical ventilation are successfully weaned from the respirator in the WU. Nevertheless, the proportion of patients with weaning failure and subsequent invasive long-term out-of-hospital ventilation as well as the mortality rate in the WU and after discharge were high. The ethical implications of these observations are discussed in the paper.